about US$3,000 per year initially but can decline thereafter to US$300 per year (Kher 2002). Kidney transplants are cheaper in India than in the United States, ranging from US$1,500 in government hospitals to as much as US$7,000 in private hospitals. Such costs, combined with a higher quality of life than obtained with dialysis, make renal transplantation the most cost-effective option (table 36.3). However, the availability of kidneys is a major limiting factor. Developed countries tend to have well-organized organ retrieval programs, and cadaveric donor transplants are more common than they are in developing countries. Japan, with its extremely low transplant rates, is an exception, perhaps because of difficulties in obtaining permission for organ donation. Developing countries have limited access to cadaveric donor programs but better living donor programs. Unrelated living donors are more common than in developed countries because poverty increases the willingness of donors to offer kidneys in Diseases of the Kidney and the Urinary System | 701 Table 36.3 Cost-Effectiveness of Selected Interventions for Kidney Disease Sources: a Winkelmayer and others 2002 (review); b authors’ rough estimates; c Satko and Freedman 2001; d Golan, Birkmeyer, and Welch 1999; e Kiberd and Jindal 1998. Intervention Center hemodialysisa Home hemodialysisa Kidney transplanta ACE inhibitors for all type 1 diabetics with macroproteinuriab Screening diabetic relatives of nephropathy patientsc Treat all type 2 diabetics with ACE inhibitorsd Treat all insulindependent diabetics with ACE inhibitorse Alternative No RRT No RRT No RRT No RRT No screening Screening for microalbuminuria and treating those who test positive Screening for microalbuminuria or macroproteinuria and treating those who test positive Outcome (2000 US$) 55,000–80,000/life year 79,000–114,000/QALY 33,000–50,000/life year 47,000–71,000/QALY 10,000/life year 11,000/QALY 1,100/QALY Screening potentially cost saving Incremental costeffectiveness ratio is 7,500/QALY for treating all type 2 diabetics Treating all insulin-dependent diabetics dominates under a plausible range of parameters exchange for payment. The Philippines recently restricted donations to “emotionally related” donors, but that limitation does not prevent abuses, such as men marrying women of the appropriate blood type in the hope of obtaining a kidney. Developing countries face particular transplantation problems, such as patients’ inability to continue paying for immunosuppressive drugs and the transmission of hepatitis B and C, malaria, and TB through organ transplant (Kher 2002). Long-term hemodialysis was introduced in 1960 and is the most costly treatment option at approximately US$60,000 per year at a center and US$40,000 at home in developed countries. It is most cost-effective if used as an interim measure before kidney transplant. Peritoneal dialysis—for example, continuous ambulatory peritoneal dialysis—was developed in the late 1970s and is less expensive—approximately US$20,000 per year (Winkelmayer and others 2002). Most economies continue to rely on hemodialysis for dialysis patients, except for those mandating that continuous ambulatory peritoneal dialysis be the first choice—that is, Hong Kong (China), Mexico, New Zealand, and the United Kingdom. Switching to continuous ambulatory peritoneal dialysis has the potential of reducing costs for developing countries, especially if they manufacture the consumables domestically rather than importing them. Nevertheless, dialysis remains costly and is not a viable long-term solution in places where health budgets are limited. More than 120 countries have dialysis programs (Moeller, Gioberge, and Brown 2002). The following data from India highlight the stark economics of dialysis (Kher 2002). Government hospitals will provide hemodialysis only for acute renal failure or pretransplant stabilization (Li and Chow 2001), and with an incidence of 100 per million population, approximately 100,000 patients develop ESRD each year. Of the 10,000 who consult a nephrologist, RRT is initiated for 9,000. Of the 8,500 who begin hemodialysis, about 60 percent are lost to follow-up within three months, probably because of the costs involved. Few remain on dialysis after 24 months. Between 17 and 23 percent of those on dialysis for two to three months receive transplants. IMPLEMENTATION OF CONTROL STRATEGIES: LESSONS OF EXPERIENCE Measures for primary and secondary prevention of CKD are now well documented and will eventually reduce the number of patients requiring dialysis. Until recently, the focus has been on RRT to save lives, and considerable efforts are being made to improve the quality of dialysis. In the United States, guidelines derived from the Kidney Disease Outcomes Quality Initiative have added greatly to the quality of dialysis in terms of access (graft or fistula), adequacy, treatment of anemia, treatment of secondary hyperparathyroidism, and—more recently—greater emphasis on CVD, all of which contribute to quality-of-life outcomes, but at an increased cost (National Kidney Foundation 2002). The high mortality rate of dialysis approximates 10 percent per year and has changed little over the past decade; however, new approaches are emerging for dealing